Motivations for and experiences of childbirth abroad amongst Nigerian women: A qualitative study

Birth tourism, the practice of a woman travelling out of her country of residence to another country to give birth, is common globally. Despite this, there is limited literature on the motivations and experiences of women who gave birth abroad. This study aims to address this gap by seeking to understand the motivations for and experiences of childbirth abroad among Nigerian women. Using purposive and snowball sampling, 27 Nigerian women who had children abroad were recruited via social media platforms. In-depth interviews were conducted remotely, audio-recorded, transcribed, and analysed thematically. Braun and Clarke’s six-step thematic analysis was used, which included data familiarisation, code generation, searching for themes, reviewing themes, defining themes, and producing the report. We found that motivations for seeking childbirth abroad varied based on the mother’s desires for their children, needs, and circumstances. These motivations were formed at different times before and after pregnancy and evolved over time. The experience of childbirth abroad is mostly good. However, there are also bad experiences, with some women feeling like they were treated differently because they were “self-paying” patients, “black”, or not country residents. The cost of care is deemed exorbitant, but most pay their bills. Support of loved ones around childbirth abroad was considered crucial, although not always available. Through it all, realising the expected and collateral benefits of childbirth abroad made it all worth it. In conclusion, motivation for childbirth abroad varies and evolves. While globalisation, broken health systems, and ongoing sustained economic challenges in Nigeria and similar settings continue to motivate women to seek childbirth abroad, their experiences of childbirth abroad suggest that though it might be greener on the other side, it is not necessarily dark green. Systems are needed to elevate their voices in the public discourse and safeguard them from bad experiences of childbirth abroad.

In the methods section you write that collection of data continued until thematic saturation was achieved, however in the discussion you write "However, we continued data collection beyond when data saturation was achieved and continued with additional IDIs as long as we had an opportunity to recruit Nigerian pregnant women to the study."Explain and make this clear in the method section, please.
Response: Thank you for picking this discrepancy.We have aligned both to reflect continuing data collection until thematic saturation was achieved (Page 6, Paragraph 2 and Page 23, Paragraph 2).
I really like that you confirmed your findings with the interviewees, I'd call it "member -checking" Response: Thank you for this comment.Indeed, this is the technical nomenclature.We decided to keep our more descriptive narrative of what we did in this case (Page 6, Paragraph 2).This lay description is captured in the paper below: Birt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qualitative Health Research. 2016;26(13):1802-1811.
I would strongly recommend you use an additional reference to the Braun and Clarke reference from 2006.They have developed the method a lot since then and published a lot on the developments (as an example they call their method "Reflexive thematic analysis" now).
Response: Thanks for flagging this to us.Much appreciated.We have another reference from Braun and Clarke.See Ref 29.As we have not used this method, as now described "reflexive thematic analysis" in this study, we decided against citing any additional sources.
The analysis need to be further explained, it is very brief now and does not explain the process, how were categories/themes developed, who were involved and so on (see the SRQR checklist) Response: Thank you for pointing us to this.We have expanded our explanation of our description of our data analysis, explaining the process in granular details, how we coded, and how the themes were developed and refined (Page 6, Paragraph 4).
I don't understand how the sex of the babies are important for the findings?I would delete that result.
Response: The sex of babies has been highlighted in the literature as informing the choice of Chinese Women to seek childbirth abroad.We were keen to see if this is the case amongst Nigerian women also, especially as there is a recognised boy preference in the society.The themes seem underdeveloped, Braun and Clarke explains it as "theme captures an aspect of patterned meaning in the data and tells the reader something about the shared meaning within it, whereas a topic summary simply summarizes participant's responses relating to a particular topic".To me these themes are topic summaries.I think you can dig deeper into the data and find better themes.
Response: Thank you for this comment.We have reviewed our transcripts again and where necessary draw out patterns in the results.We think this comment might be about style of qualitative research presentation.Our approach was to describe the themes in results and draw patterns while discussing the themes under the Discussion.This is an approach used by many qualitative researchers in published literature.See some recent papers in PLOS Global Public Health: Baez Caraballo P, Schriger S, Escober J, Acevedo A, García Alejandro A, Halpern M, et al. (2023) Reaching "covidianidad": A qualitative study of the impact of the COVID-19 pandemic on the perceived mental health of health care workers in the Dominican Republic.PLOS Glob Public Health 3( 12 The quotes often outnumber the describing text in the results which makes me as a reader think the interviews are under-analyzed.As the quotes are often very long and also stacked on top of each other, I recommend you describe more in the text and delete at least half of the quotes (and shorten them).
Response: Thank you for this comment.For such a complex, rarely studied and multi-dimensional topic (country of birth, obstetric history and complication etc.), it is not unusual to have many quotes.It is also important that the narratives of the experiences of women were fully reflected.See example in published literature: Introduction This is adequate as the necessary parts of the introduction can be seen (background, problem and objective).
Response: Thank you for your kind comment.Much appreciated.

Methodology
In the data analysis section, the authors should specify the exact type of thematic analysis used.
Response: Thank you for this comment.We have now specified that we have used a deductive thematic analysis (Page 6, Paragraph 4).

Discussion
The discussion section is adequate.The authors should add a separate conclusion section after the discussion.The paragraph on study strengths and limitations should be given a heading to make it stand out from the rest of the discussion section.
Response: Thank you for this suggestion.We have done this.
Fuse K (2008) Cross-National Variation in Attitudinal Measures of Gender Preference for Children: An Examination of Demographic and Health Surveys from 40 Countries.Available at: https://dhsprogram.com/pubs/pdf/WP44/WP44.pdf We have made this more clear in the manuscript in the methods and discussed the point that we have not observed any different in motivation by sex of babies (Page 23, Paragraph 4).